1
|
Favre-Bulle A, Bencina G, Zhang S, Jiang R, Andritschke D, Bhadhuri A. Cost-effectiveness of pembrolizumab as an adjuvant treatment for patients with resected stage IIB or IIC melanoma in Switzerland. J Med Econ 2023; 26:283-292. [PMID: 36748342 DOI: 10.1080/13696998.2023.2174748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM To assess the cost-effectiveness of adjuvant pembrolizumab versus observation for patients with resected stage IIB/IIC melanoma from a third-party payers' perspective in Switzerland over a lifetime horizon. MATERIALS AND METHODS A Markov state transition model with four health states (recurrence-free [RF], locoregional recurrence, distant metastases [DM], and death) was developed to determine the cost-effectiveness of pembrolizumab versus observation as an adjuvant treatment in patients with stage IIB/IIC melanoma who have undergone complete resection. The model utilized data from the KEYNOTE-716 randomized controlled trial (ClinicalTrials.gov, NCT03553836). The incremental cost-effectiveness ratio (ICER) (Swiss Franc [CHF] per life year or quality-adjusted life years [QALYs] gained) was calculated. A probabilistic sensitivity analysis and deterministic sensitivity analysis were conducted to assess the robustness of the base case results. RESULTS Model results demonstrated that pembrolizumab is highly cost-effective as an adjuvant treatment for resected stage IIB/IIC melanoma versus observation in Switzerland. Base case results showed an ICER of CHF 27,424/QALY (EUR 27,342/QALY; exchange rate: 1 CHF = 0.997 EUR) for pembrolizumab versus observation. Results were most sensitive to changes to transition probabilities from the RF state. Most sensitivity and scenario analyses resulted in ICERs below the willingness-to-pay threshold (WTP) of CHF 100,000. At this WTP, pembrolizumab had a 78.9% probability of being cost-effective versus observation. LIMITATIONS Due to a limited follow-up period in the KEYNOTE-716 trial, data from other clinical trials in the advanced melanoma setting were synthesized in a network meta-analysis and used to inform transition probabilities from DM to death in the cost-effectiveness model, to overcome the absence of these data from the trial. CONCLUSION The model demonstrated that pembrolizumab is highly cost-effective versus observation in patients with resected stage IIB/IIC melanoma in Switzerland. The ICER was below the WTP threshold of CHF 100,000, commonly used for cost-effectiveness models in Switzerland.
Collapse
Affiliation(s)
| | | | | | | | | | - Arjun Bhadhuri
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
| |
Collapse
|
2
|
Wahler S, Müller A, Fuchs S, von der Schulenburg JM. Adjuvant treatment of high-risk melanoma - cost-effectiveness analysis of treatment options for BRAF 600 mutated tumors. HEALTH ECONOMICS REVIEW 2022; 12:8. [PMID: 35059911 PMCID: PMC8780795 DOI: 10.1186/s13561-021-00347-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 12/08/2021] [Indexed: 05/22/2023]
Abstract
INTRODUCTION Until recently, adjuvant treatment options for higher stage resectable cutaneous melanoma were limited. Two studies with a similar set-up, published 2017, led to registration of targeted therapy for BRAF-mutated melanoma with dabrafenib and trametinib as well as of the immunotherapy with nivolumab irrespective of BRAF-mutation status. Both options have been positively assessed in Germany since 2019 for the adjuvant treatment of BRAF-V600 mutated melanoma. This study evaluates the cost-effectiveness of both treatment alternatives (dabrafenib/trametinib and nivolumab) against observation as a comparative therapy from the perspective of German statutory health funds. METHODS Partitioned survival analysis based on published survival curves for the investigated treatment options was used for a cohort model for the health states relapse free survival, progression, and death. The partitioned survival analysis approach was based on the survival curves published for the key studies Combi AD and Checkmate-238. The modelling was performed for the remaining lifetime for a cohort with starting age of 50 years. For extrapolation of the survival curves, convergence to general population mortality rates was assumed in the long term. Within the progression state, a Markov model uses three levels of progressions (locoregional, distant metastases with 1st and 2nd line treatment). Lifetime treatment costs were calculated using the German statutory health fund reimbursement scheme. Quality adjusted life years (QALYs) associated to the health states were adopted from previously published utilities based on the Combi AD study. RESULTS The treatment with dabrafenib/trametinib yielded an increase in quality adjusted life years of 2.28 QALY at an incremental lifetime cost of 86.1 T€. The incremental cost effectiveness ratio of dabrafenib/trametinib and nivolumab was comparable with 37.8 T€/QALY and 30.0 T€/QALY, respectively. Several sensitivity analyses proved the result to be insensitive. General model parameters like discount rate and length of the time horizon had stronger influence. For nivolumab, the model showed lower discounted lifetime costs (118.1 T€) compared to dabrafenib/trametinib [155.1 T€], associated with a lower gain in QALYs (1.64 years) compared to observation. CONCLUSION Both dabrafenib/trametinib and nivolumab turned out to be cost effective within internationally accepted Incremental Cost Effectiveness Ratio (ICER) thresholds with comparable cost effectiveness ratios.
Collapse
Affiliation(s)
- Steffen Wahler
- St. Bernward GmbH, Friedrich-Kirsten-Straße 40, D-22391, Hamburg, Germany.
| | - Alfred Müller
- Analytic Services GmbH, Jahnstr. 34c, D-80469, Munich, Germany
| | - Sabine Fuchs
- Novartis Pharma GmbH, Roonstr. 25, D-90429, Nuremberg, Germany
| | | |
Collapse
|
3
|
Bensimon AG, Zhou ZY, Jenkins M, Song Y, Gao W, Signorovitch J, Krepler C, Liu FX, Wang J, Aguiar-Ibáñez R. Cost-effectiveness of pembrolizumab for the adjuvant treatment of resected high-risk stage III melanoma in the United States. J Med Econ 2019; 22:981-993. [PMID: 31012765 DOI: 10.1080/13696998.2019.1609485] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 03/27/2019] [Accepted: 04/11/2019] [Indexed: 10/27/2022]
Abstract
Aims: To evaluate the cost-effectiveness of adjuvant pembrolizumab relative to observation alone following complete resection of high-risk stage III melanoma with lymph node involvement, from a US health system perspective. Materials and methods: A Markov cohort model with four health states (recurrence-free, locoregional recurrence, distant metastases, and death) was developed to estimate costs, life-years, and quality-adjusted life-years (QALYs) associated with pembrolizumab vs observation over a lifetime (46-year) horizon. Using a parametric multi-state modeling approach, transition probabilities starting from recurrence-free were estimated based on patient-level data from KEYNOTE-054 (NCT02362594), a direct head-to-head phase 3 trial. Post-recurrence transition probabilities were informed by real-world retrospective data and clinical trials in advanced melanoma. Health state utilities and adverse event-related disutility were derived from KEYNOTE-054 trial data and published literature. Costs of drug acquisition and administration, adverse events, disease management, and terminal care were estimated in 2018 US dollars. Deterministic and probabilistic sensitivity analyses were conducted to assess robustness. Results: Over a lifetime horizon, adjuvant pembrolizumab and observation were associated with total QALYs of 9.24 and 5.95, total life-years of 10.54 and 7.15, and total costs of $489,820 and $440,431, respectively. The resulting incremental cost-effectiveness ratios (ICERs) for pembrolizumab vs observation were $15,009/QALY and $14,550/life-year. Across the range of input values and assumptions tested in deterministic sensitivity analyses, pembrolizumab ranged from being a dominant strategy to having an ICER of $57,449/QALY vs observation. The ICER was below a willingness-to-pay threshold of $100,000/QALY in 90.2% of probabilistic simulations. Limitations: Long-term extrapolation of outcomes was based on interim results from KEYNOTE-054, with a median follow-up of 15 months. Conclusions: Based on common willingness-to-pay benchmarks, pembrolizumab is highly cost-effective compared with observation alone for the adjuvant treatment of completely resected stage III melanoma in the US.
Collapse
Affiliation(s)
| | | | | | - Yan Song
- Analysis Group Inc. , Boston , MA , USA
| | - Wei Gao
- Analysis Group Inc. , Boston , MA , USA
| | | | | | | | | | | |
Collapse
|
4
|
Abstract
Although melanoma is a rare diagnosis in the pediatric population, advances in the management of adults with melanoma offer the prospect of promising therapeutic options for children. At this time, medical management is not considered curative but may reduce the risk of recurrence or prolong survival. Surgical management remains the mainstay of treatment. Medical therapy of pediatric melanoma is not thought to have a role for in situ, early-stage, or localized disease, but adjuvant therapy may have a role in improving the prognosis of patients with positive sentinel lymph node biopsy (SLNB), spread beyond the regional lymph node basin, metastatic disease, or recurrent disease. Medical treatment options include immunotherapies, particularly checkpoint inhibitors, and targeted therapies, which have provided improved toxicity profiles compared with traditional chemotherapy regimens in the setting of advanced disease. There is a growing body of pediatric-specific data relevant to the use of adjuvant therapies for advanced melanoma in children.
Collapse
|
5
|
Rubio-Rodríguez D, De Diego Blanco S, Pérez M, Rubio-Terrés C. Cost-Effectiveness of Drug Treatments for Advanced Melanoma: A Systematic Literature Review. PHARMACOECONOMICS 2017; 35:879-893. [PMID: 28551858 DOI: 10.1007/s40273-017-0517-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND Until recently, advanced melanoma (unresectable and metastatic) has had a poor prognosis and has been treated with chemotherapy. The introduction of new treatments (BRAF and MEK inhibitors and immunotherapy) has improved overall survival and progression-free survival of some patients. OBJECTIVE The objective of this study was to review the published evidence on the cost-effectiveness of pharmacological treatments for advanced melanoma. METHODS A systematic literature search was conducted, without date or language restrictions, in PubMed, EMBASE, Scopus, the Cochrane Library, the UK National Institute for Health and Care Excellence databases and the Health Technology Assessment journal. Internet searches were also made to identify possible grey literature. Main study characteristics, methods and outcomes were extracted and critically assessed. The quality of health economic studies was assessed by the Quality Assessment of Economic Evaluation in Health Care checklist. RESULTS The search identified nine full-text pharmacoeconomic analyses of advanced melanoma treatments. According to the economic analyses published in the articles, the new treatments have been shown to be more effective (with more life-years and quality-adjusted life-years) than chemotherapy, although generally the cost per quality-adjusted life-year gained was above the commonly accepted threshold. Because of the variability of the available analyses comparing the new treatments, we cannot determine which treatment is the most cost-effective. CONCLUSIONS From the available data, it cannot be concluded that the new drugs (BRAF and MEK inhibitors and immunotherapy) are cost effective compared with chemotherapy or which is the most cost-effective new treatment.
Collapse
Affiliation(s)
| | | | - Maite Pérez
- Medical Department, AstraZeneca Farmacéutica Spain, Barcelona, Spain
| | | |
Collapse
|
6
|
van Zeijl MCT, van den Eertwegh AJ, Haanen JB, Wouters MWJM. (Neo)adjuvant systemic therapy for melanoma. Eur J Surg Oncol 2016; 43:534-543. [PMID: 27453302 DOI: 10.1016/j.ejso.2016.07.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 06/28/2016] [Accepted: 07/04/2016] [Indexed: 11/28/2022] Open
Abstract
Surgery still is the cornerstone of treatment for patients with stage II and III melanoma, but despite great efforts to gain or preserve locoregional control with excision of the primary tumour, satellites, intransits, sentinel node biopsy and lymphadenectomy, surgery alone does not seem to improve survival any further. Prognosis for patients with high risk melanoma remains poor with 5-year survival rates of 40 to 80%. Only interferon-2b has been approved as adjuvant therapy since 1995, but clinical integration is low considering the high risk-benefit ratio. In recent years systemic targeted- and immunotherapy have proven to be beneficial in advanced melanoma and could be a promising strategy for (neo)adjuvant treatment of patients with resectable high risk melanomas as well. Randomised, placebo- controlled phase III trials on adjuvant systemic targeted- and immunotherapy are currently being performed using new agents like ipilimumab, pembrolizumab, nivolumab, vemurafenib and dabrafenib plus trametinib. In this article we review the literature on currently known adjuvant therapies and currently ongoing trials of (neo)adjuvant therapies in high risk melanomas.
Collapse
Affiliation(s)
- M C T van Zeijl
- Dutch Institute for Clinical Auditing, Rijnsburgerweg 10, 2333AA Leiden, The Netherlands; Department of Surgery, Leiden University Medical Centre, Albinusdreef 2, 2333ZA Leiden, The Netherlands.
| | - A J van den Eertwegh
- Department of Medical Oncology, VU University Medical Center, De Boelelaan 1118, 1081HZ Amsterdam, The Netherlands
| | - J B Haanen
- Department of Medical Oncology and Immunology, Netherlands Cancer Institute, Plesmanlaan 121, 1066CX Amsterdam, The Netherlands
| | - M W J M Wouters
- Dutch Institute for Clinical Auditing, Rijnsburgerweg 10, 2333AA Leiden, The Netherlands; Department of Surgical Oncology, Netherlands Cancer Institute, Plesmanlaan 121, 1066CX Amsterdam, The Netherlands
| |
Collapse
|
7
|
Navid F, Herzog CE, Sandoval J, Daryani VM, Stewart CF, Gattuso J, Mandrell B, Phipps S, Chemaitilly W, Sykes A, Davidoff AM, Shulkin BL, Bahrami A, Furman WL, Mao S, Wu J, Schiff D, Rao B, Pappo A. Feasibility of Pegylated Interferon in Children and Young Adults With Resected High-Risk Melanoma. Pediatr Blood Cancer 2016; 63:1207-13. [PMID: 27038395 PMCID: PMC4877209 DOI: 10.1002/pbc.25983] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 02/27/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pegylated interferon α-2b (IFN α-2b) improves disease-free survival in adults with resected stage III melanoma. We conducted a study to determine the feasibility and safety of incorporating pegylated IFN α-2b as adjuvant therapy in the treatment of children and adolescents with high-risk melanoma. Pharmacokinetic studies of IFN α-2b and neuropsychological and quality of life (OL) assessments were performed. PATIENT AND METHODS Eligible patients with resected American Joint Committee on Cancer Stage IIC, IIIA, and IIIB cutaneous melanoma received nonpegylated IFN α-2b 20 million units/m(2) /day intravenously 5 days per week for 4 weeks (induction) followed by pegylated IFN α-2b 1 μg/kg/dose weekly subcutaneously (SQ) for 48 weeks (maintenance). RESULTS Twenty-three patients (15 females, median age 10 years) were enrolled. All patients completed induction therapy; five patients did not complete maintenance therapy either because of recurrent disease (n = 2) or toxicity (n = 3). The most common grade 3 and 4 toxicities of pegylated IFN α-2b were neutropenia (35%) and elevated liver transaminases (17%). The median nonpegylated IFN α-2b AUC0-∞ (5,026 pcg⋅hr/ml) was similar to adults. The median pegylated IFN α-2b exposure (48,480 pcg⋅hr/ml) was greater than the cumulative weekly exposure for nonpegylated IFN α-2b administered SQ three times per week (TIW). Validated measures demonstrated an improvement in QOL scores and no decline in psychological functioning over the course of therapy. CONCLUSIONS Pegylated IFN α-2b 1 μg/kg/dose SQ weekly as maintenance therapy in children and adolescents with high-risk melanoma is feasible with tolerable toxicity and appears to yield higher exposures than nonpegylated IFN α-2b administered SQ TIW.
Collapse
Affiliation(s)
- Fariba Navid
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN
| | | | - John Sandoval
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Vinay M. Daryani
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - Clinton F. Stewart
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - Jami Gattuso
- Department of Nursing Research, St. Jude Children's Research Hospital, Memphis, TN
| | - Belinda Mandrell
- Department of Nursing Research, St. Jude Children's Research Hospital, Memphis, TN
| | - Sean Phipps
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, TN
| | - Wassim Chemaitilly
- Department of Pediatric Medicine-Division of Endocrinology, St. Jude Children's Research Hospital, Memphis, TN
| | - April Sykes
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN
| | - Andrew M. Davidoff
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Barry L. Shulkin
- Department of Radiological Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - Armita Bahrami
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN
| | - Wayne L. Furman
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN
| | - Shenghua Mao
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN
| | - Jianrong Wu
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN
| | - Deborah Schiff
- Department of Pediatrics, University of California-San Diego, La Jolla, CA
| | - Bhaskar Rao
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Alberto Pappo
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN,Corresponding author: Alberto Pappo, MD, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, Memphis TN 38105, Telephone: (901) 595-2322, FAX: (901) 521-9005,
| |
Collapse
|
8
|
Voss RK, Woods TN, Cromwell KD, Nelson KC, Cormier JN. Improving outcomes in patients with melanoma: strategies to ensure an early diagnosis. PATIENT-RELATED OUTCOME MEASURES 2015; 6:229-42. [PMID: 26609248 PMCID: PMC4644158 DOI: 10.2147/prom.s69351] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Patients with thin, low-risk melanomas have an excellent long-term prognosis and higher quality of life than those who are diagnosed at later stages. From an economic standpoint, treatment of early stage melanoma consumes a fraction of the health care resources needed to treat advanced disease. Consequently, early diagnosis of melanoma is in the best interest of patients, payers, and health care systems. This review describes strategies to ensure that patients receive an early diagnosis through interventions ranging from better utilization of primary care clinics, to in vivo diagnostic technologies, to new "apps" available in the market. Strategies for screening those at high risk due to age, male sex, skin type, nevi, genetic mutations, or family history are discussed. Despite progress in identifying those at high risk for melanoma, there remains a lack of general consensus worldwide for best screening practices. Strategies to ensure early diagnosis of recurrent disease in those with a prior melanoma diagnosis are also reviewed. Variations in recurrence surveillance practices by type of provider and country are featured, with evidence demonstrating that various imaging studies, including ultrasound, computed tomography, positron emission tomography, and magnetic resonance imaging, provide only minimal gains in life expectancy, even for those with more advanced (stage III) disease. Because the majority of melanomas are attributable to ultraviolet radiation in the form of sunlight, primary prevention strategies, including sunscreen use and behavioral interventions, are reviewed. Recent international government regulation of tanning beds is described, as well as issues surrounding the continued use artificial ultraviolet sources among youth. Health care stakeholder strategies to minimize UV exposure are summarized. The recommendations encompass both specific behaviors and broad intervention targets (eg, individuals, social spheres, organizations, celebrities, governments).
Collapse
Affiliation(s)
- Rachel K Voss
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tessa N Woods
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kate D Cromwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kelly C Nelson
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Janice N Cormier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
9
|
Zhang Y, Le TK, Shaw JW, Kotapati S. Retrospective analysis of drug utilization, health care resource use, and costs associated with IFN therapy for adjuvant treatment of malignant melanoma. CLINICOECONOMICS AND OUTCOMES RESEARCH 2015; 7:397-407. [PMID: 26229494 PMCID: PMC4516031 DOI: 10.2147/ceor.s78704] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background This study examines real-world drug utilization patterns, health care resource use, and costs among patients receiving adjuvant treatment with IFN versus patients receiving no treatment (“observation”) for malignant melanoma following surgery. Methods A retrospective cohort study was conducted using administrative claims from Truven Health Analytics (MarketScan®) to identify all adjuvant melanoma patients (aged ≥18 years) diagnosed between June 2007 and June 2011 who had a lymph node dissection (ie, index surgery) and were treated with IFN or subsequently observed. Health care resource use and costs of services were converted to 2012 US dollars and were evaluated and compared using multivariable regression. Results Of 1,999 eligible subjects with melanoma surgery claims, 179 (9.0%) were treated with IFN and 1,820 (91.0%) were observed. The median duration (days) and number of doses of IFN therapy were 73 and 36, respectively. Among IFN-treated patients, only 10.6% completed ≥80% of maintenance therapy. The total average cost for patients treated with IFN was US$60,755±$3,972 (n=179); significantly higher than for patients undergoing observation ($31,641±$2,471; P<0.0001). Similar trends were observed when evaluating total cost components, including melanoma-related and non-melanoma–related medical costs. Among the melanoma-related medical costs, outpatient services, including office visits and laboratory testing, represented between 33% and 53% of total costs and demonstrated the largest difference between IFN-treated and observation patients. Outpatient service costs for IFN-treated patients were $32,414±$2,498, over three times greater than those for observation patients ($10,556±$1,128; P<0.0001). Conclusion The majority of adjuvant melanoma patients in this study was treated with observation versus IFN treatment. Among those who attempted IFN treatment, most could not complete the recommended course of therapy. Health care costs were significantly greater for patients treated with IFN, with the greatest differences being for melanoma-related medical cost components. These findings illustrate the significant economic burden borne by adjuvant melanoma patients and their health insurers.
Collapse
Affiliation(s)
- Ying Zhang
- Center for Observational Research and Data Sciences, Worldwide Health Economics and Outcomes Research, Bristol-Myers Squibb Research and Development, Hopewell, NJ, USA
| | - Trong Kim Le
- Center for Observational Research and Data Sciences, Worldwide Health Economics and Outcomes Research, Bristol-Myers Squibb Research and Development, Hopewell, NJ, USA
| | - James W Shaw
- Worldwide Health Economics and Outcomes Research, Bristol-Myers Squibb Research and Development, Princeton, NJ, USA
| | - Srividya Kotapati
- Worldwide Health Economics and Outcomes Research, Bristol-Myers Squibb Research and Development, Wallingford Center, CT, USA
| |
Collapse
|
10
|
Hu Y, Shah P, Stukenborg GJ, Slingluff CL. Utility of sentinel lymph node biopsy for solitary dermal melanomas. J Surg Oncol 2015; 111:800-7. [PMID: 25712273 PMCID: PMC4436976 DOI: 10.1002/jso.23890] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 01/02/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Solitary dermal melanoma (SDM) is melanoma confined to subcutaneous and/or dermal layers in the absence of a known primary cutaneous lesion. We hypothesized that sentinel node biopsy is an effective staging strategy for this rare disease. METHODS A Markov decision model was constructed to represent two management strategies for SDM: wide local excision followed by observation, and wide local excision followed by sentinel node biopsy. Utilities, likelihood of positive sentinel node biopsy, and cancer progression rates during a five year time horizon were assigned based on institutional data and a review of existing literature. Estimated costs were derived using Medicare reimbursements. RESULTS Excision followed by sentinel node biopsy provides greater utility, yielding 3.85 discounted quality-adjusted life years (dQALY) compared to 3.66 for excision alone. The incremental cost-effectiveness ratio for sentinel node biopsy is $19,102 per dQALY. Sensitivity analyzes demonstrated that observation is more cost-effective if greater than 23% of sentinel node biopsies are positive (16% reported), or if 5-year survival for observed patients is greater than 76% (69% reported). CONCLUSIONS Based on existing clinical evidence, sentinel node biopsy yields greater utility than excision alone and is cost-effective for patients presenting with solitary dermal melanoma.
Collapse
Affiliation(s)
- Yinin Hu
- Department of Surgery/Division of Surgical Oncology, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - Puja Shah
- Department of Surgery/Division of Surgical Oncology, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - George J. Stukenborg
- Department of Public Health Sciences, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - Craig L. Slingluff
- Department of Surgery/Division of Surgical Oncology, University of Virginia Health System, Charlottesville, VA 22908, USA
| |
Collapse
|
11
|
Johnston KM, McPherson E, Osenenko K, Vergidis J, Levy AR, Peacock S. Cost-effectiveness of therapies for melanoma. Expert Rev Pharmacoecon Outcomes Res 2015; 15:229-42. [PMID: 25703441 DOI: 10.1586/14737167.2015.1017563] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Melanoma presents an important burden worldwide. Until recently, the prognosis for unresectable and metastatic melanoma was poor, with 10% of metastatic melanoma patients surviving for 2 years. The introduction of newer therapies including ipilimumab, vemurafenib, dabrafenib and trametinib improved progression-free survival, with additional benefits anticipated from the forthcoming class of programmed cell death 1 inhibitors. Cost of therapy and resulting cost-effectiveness is an important factor in determining patient access to specific treatments. The objective of this study was to review the published evidence regarding cost-effectiveness of melanoma therapies and provide an overview of the relative cost-effectiveness of available therapies by disease stage. For earlier-stage disease, IFN-α has been found to be cost-effective, although its clinical benefits have not been well established. For unresectable and metastatic melanoma, newer therapies provide benefits over standard-of-care chemotherapy, but comprehensive analyses will need to be conducted to determine the most cost-effective therapy.
Collapse
|
12
|
Rueth NM, Xing Y, Chiang YJ, Cromwell KD, Ross MI, Lee JE, Gershenwald JE, Royal RE, Cormier JN. Is surveillance imaging effective for detecting surgically treatable recurrences in patients with melanoma? A comparative analysis of stage-specific surveillance strategies. Ann Surg 2014; 259:1215-22. [PMID: 24096759 DOI: 10.1097/sla.0000000000000233] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To guide resource utilization, we aimed to determine the impact of routine surveillance imaging for the detection of melanoma recurrences amenable to surgical resection with curative intent. BACKGROUND The National Comprehensive Cancer Network guidelines for melanoma surveillance are largely consensus based. METHODS Using single-institution, patient-level data (n = 1600), transition probabilities were calculated for a Markov model simulating the natural history of patients with stage I-III melanoma. As a base estimate, imaging was assumed to detect regional and distant recurrences of which 80% and 20% could be surgically treated with curative intent, respectively. Sensitivity analyses were conducted for all point estimates. For each disease stage, we calculated the number of surgically treatable regional or distant recurrence detected during 5 years per 10,000 patients undergoing computed tomography (CT) or positron emission tomography (PET)/CT scans at 6- or 12-month intervals. The associated positive and negative predictive values and life expectancy were also calculated and compared with clinical examination alone. RESULTS At 5-year follow-up, CT or PET/CT at 6-month intervals detected surgically treatable regional or distant recurrence in 6.4% of patients with stage I, 18.5% of stage II, and 33.1% of stage III disease; 12-month intervals decreased the rates to 3.0%, 7.9%, and 13.0%, respectively. The high false-positive rates of CT (20%) and PET/CT (9%) resulted in overall low positive predictive values. However, both CT and PET/CT effectively predicted absence of disease. Life-expectancy gains were minimal (≤ 2 months) for all groups. CONCLUSIONS The effectiveness of routine surveillance imaging for detecting treatable melanoma recurrences is limited. Even in patients with stage III disease, only minimal gains in life expectancy were achieved.
Collapse
Affiliation(s)
- Natasha M Rueth
- *Department of Surgical Oncology †Institute of Cancer Care Excellence ‡Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Gibbons E, Casañas i Comabella C, Fitzpatrick R. A structured review of patient-reported outcome measures for patients with skin cancer, 2013. Br J Dermatol 2014; 168:1176-86. [PMID: 23488455 DOI: 10.1111/bjd.12310] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND The collection of patient-reported outcome measures (PROMs) within the national PROMs programme for elective procedures is now established mandatory practice in the NHS with high response rates and completion. OBJECTIVES This review examines the evidence of PROMs for people with skin cancer. METHODS Comprehensive searches were conducted using several sources and databases, using a detailed search strategy developed by the University of Oxford's PROM Group. Articles were assessed for eligibility. Data were extracted per PROM for each measurement property and appraised using an appraisal framework. RESULTS A total of 3517 articles were identified in the searches, and 28 were included in the final review after assessment by two independent reviewers. Two generic instruments (SF-36 and Sickness Impact Profile) and nine condition-specific PROMs were identified. CONCLUSIONS Overall, there is a limited volume of published evidence for the application of generic PROMs for people with skin cancer. Evaluation of the EQ-5D may be particularly important given its widespread use in many other healthcare contexts in the U.K. The Skin Cancer Index could be considered for piloting in the NHS. For patients with nonmelanoma skin cancers, the Skindex measures may also be considered. The SCQOLIT has some evidence of applicability across both skin cancer types but more evaluations are needed. The FACT-M does have more promising characteristics for patients with malignant melanomas although no evidence of testing in the U.K. was found. The forthcoming EORTC-M may prove a useful measure given the expertise and track record of this European collaboration in cancer and quality of life.
Collapse
Affiliation(s)
- E Gibbons
- Patient-reported Outcome Measurement Group, Department of Public Health, University of Oxford, Old Road Campus, Oxford, OX3 7LF, UK.
| | | | | |
Collapse
|
14
|
Fleming NH, Tian J, Vega-Saenz de Miera E, Gold H, Darvishian F, Pavlick AC, Berman RS, Shapiro RL, Polsky D, Osman I. Impact of age on the management of primary melanoma patients. Oncology 2013; 85:173-81. [PMID: 24008821 DOI: 10.1159/000351499] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 04/18/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Age is an understudied factor when considering treatment options for melanoma. Here, we examine the impact of age on primary melanoma treatment in a prospective cohort of patients. METHODS We used logistic regression models to examine the associations between age and initial treatment, using recurrence and melanoma-specific survival as endpoints. RESULTS 444 primary melanoma patients were categorized into three groups by age at diagnosis: 19-45 years (24.3%), 46-70 (50.2%), and 71-95 (25.5%). In multivariate models, older patients experienced a higher risk of recurrence (hazard ratio 3.34, 95% confidence interval, CI, 1.53-7.25; p < 0.01). No significant differences were observed in positive biopsy margin rates or extent of surgical margins across age groups. Patients in the middle age group were more likely to receive adjuvant therapy than those in the older group (odds ratio 2.78, 95% CI 1.19-6.45; p = 0.02) and showed a trend to longer disease-free survival when receiving adjuvant therapy (p = 0.09). CONCLUSION Our data support age as an independent negative prognostic factor in melanoma. Our data suggest that age does not affect primary surgical treatment but may affect decisions of whether or not patients receive postoperative treatment(s). Further work is needed to better understand the biological variables affecting treatment decisions and efficacy in older patients.
Collapse
Affiliation(s)
- Nathaniel H Fleming
- Interdisciplinary Melanoma Cooperative Group, New York University School of Medicine, New York, N.Y., USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Wilson ECF, Emery JD, Kinmonth AL, Prevost AT, Morris HC, Humphrys E, Hall PN, Burrows N, Bradshaw L, Walls J, Norris P, Johnson M, Walter FM. The cost-effectiveness of a novel SIAscopic diagnostic aid for the management of pigmented skin lesions in primary care: a decision-analytic model. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2013; 16:356-366. [PMID: 23538188 DOI: 10.1016/j.jval.2012.12.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 11/26/2012] [Accepted: 12/09/2012] [Indexed: 06/02/2023]
Abstract
OBJECTIVES Pigmented skin lesions are commonly presented in primary care. Appropriate diagnosis and management is challenging because the vast majority are benign. The MoleMate system is a handheld SIAscopy scanner integrated with a primary care diagnostic algorithm aimed at improving the management of pigmented skin lesions in primary care. METHODS This decision-model-based economic evaluation draws on the results of a randomized controlled trial of the MoleMate system versus best practice (ISRCTN79932379) to estimate the expected long-term cost and health gain of diagnosis with the MoleMate system versus best practice in an English primary care setting. The model combines trial results with data from the wider literature to inform long-term prognosis, health state utilities, and cost. RESULTS Results are reported as mean and incremental cost and quality-adjusted life-years (QALYs) gained, incremental cost-effectiveness ratio with probabilistic sensitivity analysis, and value of information analysis. Over a lifetime horizon, the MoleMate system is expected to cost an extra £18 over best practice alone, and yield an extra 0.01 QALYs per patient examined. The incremental cost-effectiveness ratio is £1,896 per QALY gained, with a 66.1% probability of being below £30,000 per QALY gained. The expected value of perfect information is £43.1 million. CONCLUSIONS Given typical thresholds in the United Kingdom (£20,000-£30,000 per QALY), the MoleMate system may be cost-effective compared with best practice diagnosis alone in a primary care setting. However, there is considerable decision uncertainty, driven particularly by the sensitivity and specificity of MoleMate versus best practice, and the risk of disease progression in undiagnosed melanoma; future research should focus on reducing uncertainty in these parameters.
Collapse
|
16
|
Moreno Nogueira JA, Valero Arbizu M, Pérez Temprano R. Adjuvant treatment of melanoma. ISRN DERMATOLOGY 2013; 2013:545631. [PMID: 23476798 PMCID: PMC3588212 DOI: 10.1155/2013/545631] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 12/02/2012] [Indexed: 11/17/2022]
Abstract
Melanomas represent 4% of all malignant tumors of the skin, yet account for 80% of deaths from skin cancer.While in the early stages patients can be successfully treated with surgical resection, metastatic melanoma prognosis is dismal. Several oncogenes have been identified in melanoma as BRAF, NRAS, c-Kit, and GNA11 GNAQ, each capable of activating MAPK pathway that increases cell proliferation and promotes angiogenesis, although NRAS and c-Kit also activate PI3 kinase pathway, including being more commonly BRAF activated oncogene. The treatment of choice for localised primary cutaneous melanoma is surgery plus lymphadenectomy if regional lymph nodes are involved. The justification for treatment in addition to surgery is based on the poor prognosis for high risk melanomas with a relapse index of 50-80%. Patients included in the high risk group should be assessed for adjuvant treatment with high doses of Interferon- α 2b, as it is the only treatment shown to significantly improve disease free and possibly global survival. In the future we will have to analyze all these therapeutic possibilities on specific targets, probably associated with chemotherapy and/or interferon in the adjuvant treatment, if we want to change the natural history of melanomas.
Collapse
Affiliation(s)
- J. A. Moreno Nogueira
- Department of Oncology, Virgen del Rocio University Hospital, Royal Academy of Medicine, 41001 Seville, Spain
| | - M. Valero Arbizu
- Department of Oncology, Infanta Luisa Hospital, 41010 Seville, Spain
| | - R. Pérez Temprano
- Department of Medicine, Virgen Macarena University Hospital, 41014 Seville, Spain
| |
Collapse
|
17
|
Patel JN, Walko CM. Sylatron: a pegylated interferon for use in melanoma. Ann Pharmacother 2012; 46:830-8. [PMID: 22619474 DOI: 10.1345/aph.1q791] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To review the currently available literature on peginterferon alfa-2b (pegIFN [Sylatron]), including its role in therapy and toxicity for adjuvant treatment of locally advanced melanoma. DATA SOURCES A literature search was performed of PubMed and the American Society of Clinical Oncology abstracts from 1976 to February 2012, using the primary search terms peginterferon alfa-2b, interferon, Sylatron, and melanoma. STUDY SELECTION AND DATA EXTRACTION All available English-language articles and trials that described the pharmacology, pharmacokinetics, pharmacodynamics, clinical activity, or safety profile of pegIFN were reviewed. DATA SYNTHESIS PegIFN was approved in March 2011 for the adjuvant treatment of node-positive melanoma. Interferon (IFN) is commonly used in patients with melanoma who remain at high risk for relapse following surgery; however, the optimal scheduling and dose are not agreed upon. Pegylation of IFN involves conjugation with polyethylene glycol. Following subcutaneous injection of pegIFN, the rate of absorption, renal and cellular clearance, and immunogenicity are reduced. As a result of the extended serum half-life, once-weekly administration is feasible, compared with the daily and/or thrice weekly dosing of IFN. When compared with observation alone in patients with resected stage III melanoma, pegIFN demonstrated a significant increase in relapse-free survival, with a marginal impact on overall survival. The most common adverse events were as expected with IFN and included fatigue, increased liver enzymes, pyrexia, headache, anorexia, myalgia, nausea, chills, depression, and injection site reactions. A large Phase 3 study is underway to further assess outcome and toxicity differences between pegIFN weekly and low-dose IFN thrice weekly. CONCLUSIONS PegIFN is a modified version of the previously approved interferon indicated for the adjuvant treatment of melanoma. Although the safety profile remains similar between the pegylated and non-pegylated forms, once-weekly administration is feasible secondary to an extended serum half-life and may have improved convenience for the patient.
Collapse
Affiliation(s)
- Jai N Patel
- Eshelman School of Pharmacy, Division of Pharmacotherapy and Experimental Therapeutics, Institute for Pharmacogenomics and Individualized Therapy, University of North Carolina, Chapel Hill, NC, USA
| | | |
Collapse
|
18
|
Cormier JN, Askew RL. Assessment of patient-reported outcomes in patients with melanoma. Surg Oncol Clin N Am 2011; 20:201-13. [PMID: 21111967 DOI: 10.1016/j.soc.2010.09.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Assessment of patient-reported outcomes (PROs) provides important information to assist with clinical decision making. There has been significant progress in the field of PROs over the past 2 decades with the introduction of validated disease- and symptom-specific instruments. The Functional Assessment of Cancer Therapy-Melanoma (FACT-M) is a melanoma-specific module to accompany the FACT-General, which was validated to assess health-related quality of life for patients with all stages of melanoma. Melanoma-specific health state utilities also have been reported from a number of studies. Assessment of PROs should be incorporated into routine clinical practice to inform clinicians and researchers of the patient perspective for clinical decision making and to evaluate the effects of psychosocial and medical interventions.
Collapse
Affiliation(s)
- Janice N Cormier
- Department of Surgical Oncology, Unit 444, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
| | | |
Collapse
|
19
|
Sentinel node biopsy and standard of care for melanoma: A re-evaluation of the evidence. J Am Acad Dermatol 2010; 62:880-4. [DOI: 10.1016/j.jaad.2009.08.063] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2009] [Revised: 07/19/2009] [Accepted: 08/03/2009] [Indexed: 11/24/2022]
|
20
|
Sangoi A, Patel U, Ode K, Audisio R, Virgo KS, Johnson FE. Evaluation of patients with clinically detected recurrence of rectal carcinoma: Current practice patterns of colorectal surgeons. Oncol Lett 2010; 1:355-359. [PMID: 22966308 DOI: 10.3892/ol_00000063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2009] [Accepted: 10/23/2009] [Indexed: 11/06/2022] Open
Abstract
The optimal evaluation of patients with clinically suspected recurrence of rectal carcinoma following initial treatment has yet to be determined. We documented the intensity of the extent-of-disease workup conducted by colorectal surgeons when their patients with rectal carcinoma develop clinical evidence of metastases. A custom-designed questionnaire was mailed to all 1,795 members of the American Society of Colon and Rectal Surgeons. Subjects were asked which laboratory tests and imaging studies they would order for one of their own generally healthy patients with a suspicious abnormality found during surveillance testing. The tests most frequently recommended were computed tomography and serum carcinoembryonic antigen level. Few tests were recommended by >90% of respondents. There is no consensus among experts in this common situation.
Collapse
Affiliation(s)
- Ankur Sangoi
- Department of Pathology, Stanford University Medical Center, Stanford, CA 94305, USA
| | | | | | | | | | | |
Collapse
|
21
|
Anaya DA, Xing Y, Feng L, Huang X, Camacho LH, Ross MI, Gershenwald JE, Lee JE, Mansfield PF, Cormier JN. Adjuvant high-dose interferon for cutaneous melanoma is most beneficial for patients with early stage III disease. Cancer 2008; 112:2030-7. [PMID: 18320602 DOI: 10.1002/cncr.23399] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Evidence from randomized trials in the pre-sentinel lymph node biopsy era indicate that adjuvant treatment with high-dose interferon-alpha (IFN) increases recurrence-free survival (RFS) in patients with high-risk melanoma. However, to the authors' knowledge, the role of this treatment in selected patients with early stage III disease has not been well studied. METHODS The clinical and pathologic characteristics of 486 patients undergoing surgical treatment for stage III melanoma were evaluated and the authors compared outcomes for those given adjuvant treatment with IFN with those patients who had surgery alone. A particular focus was on the effect of IFN therapy on RFS and overall survival (OS) among those patients with stage IIIA disease. RESULTS The median follow-up for the entire cohort was 5.2 years; the 5-year RFS and OS rates for the entire group were 41% and 53%, respectively. Adjuvant IFN was given to 141 patients (29%). On multivariate analysis, IFN was found to be the only independent predictor for RFS in patients with stage IIIA disease (hazards ratio of 0.4; 95% confidence interval, 0.2-0.9 [P = .02]). IFN was not found to be associated with increased RFS in patients with more advanced lymph node disease (stage IIIB and stage IIIC). IFN appeared to have no effect on OS in any patient with stage III disease. CONCLUSIONS Adjuvant treatment with IFN improves RFS in melanoma patients with early stage III disease. The results of the current study should help guide management when considering adjuvant treatment for these patients.
Collapse
Affiliation(s)
- Daniel A Anaya
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030-1402, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|